EBPA - Electronic Submission

Important Submission Information HEALTHCARE CLAIMS New Claims must be submitted with a fully completed and signed Reimbursement Claim Form. NEED A HEALTHCARE FORM If you have received a Substantiation Letter or Denial Letter, please submit your receipt(s) and/or documentation with the letter you received from EBPA. DEPENDENT CARE CLAIMS The IRS guidelines are very specific for the submission of Dependent Care Claims. NEED A DEPENDENT CARE FORM


Participant's Name*:

Email Address*:

Phone Number:		() - x

Alt. Phone Number:		() - x

Group/Employer's Name*:

Document Type*:

Upload File*:


Upload File:

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Please note: The uploaded file must be DOC, DOCX, PDF, GIF, JPG, PNG, TIFF or TIF in format. The uploaded file must be less than 28MB in size. Please note: Renaming a non-supported file tyle to a suported file types will not be accepted. EXAMPLE: myreceipt.png to myreceipt.pdf Browsers supported: IE, Mozilla Firefox, Google Chrome, Safari, Edge

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